Breaking a Vicious Cycle

Robert DavidsonEditor-in-Chief

US Pharm. 2016;41(11):1.

Much is made these days about the mind-body connection, particularly when it comes to healthcare. This is far from a new, ground-breaking theory, however. The Greeks have long recognized that the brain played a role in healing and might even be the sole basis for illness. The earliest known Greek medical school opened in 700 BC, in fact, and there was significant focus on the beliefs and mind-set of the patient in ancient diagnosis and treatment theories.

As November is the Mental Health focus issue of U.S. Pharmacist as well as National Diabetes Month, this is an opportune time to explore the relationship between diabetes and depression. As reported by Kendra R. Manigault, PharmD, BCPS, BCACP, CDE, in this issue’s cover article, “The Bidirectional Relationship Between Depression and Diabetes,” patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) can find themselves overwhelmed by the day-to-day self-care treatment challenges, and these psychological stressors may, in turn, contribute to depression.

As Dr. Manigault writes, research suggests depression is increased in patients with diabetes, and the incidence of T2DM is increased in patients with depression. Depression, she adds, is often associated with marginal behavioral habits, such as a lack of physical activity and unhealthy eating, which may in and of themselves result in T2DM onset.

A meta-analysis, Dr. Manigault notes, found an increased risk of depression in patients who were diagnosed with diabetes compared with patients who had diabetes but were not cognizant of their diagnosis. And Thomas Willis, a British physician, observed as early as the late 1600s that diabetes sometimes occurred in patients after significant life stress or sorrow.

Dr. Willis’ theory seems supported by more recent research. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the symptoms of an adjustment disorder, defined as “a psychological response to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms.” These symptoms might continue longer than 6 months if triggered by a “chronic stressor (e.g., a chronic medical condition).”

Symptoms of adjustment disorders, according to DSM-5, include decreased performance at work or school and temporary changes in social relationships. In addition, they are associated with suicide attempts, suicide, excessive substance use, and sleep problems.

What does this mean for the pharmacist? While a pharmacy may not be the best—nor even an appropriate—environment for diagnosing depression, there are some simple signals that pharmacists can note. For example, when a patient refills his or her metformin prescription, is he or she especially irritable this time? Is there a noticeable change in the patient’s demeanor since his or her recent diabetes diagnosis? Or is a patient known to be taking antidepressants also now filling diabetes medication prescriptions?

Even mental health professionals, however, are often challenged to get depressed patients to avail themselves of treatment. In a recently released study published online in JAMA Internal Medicine, most patients screening positive for depression did not receive treatment within the first year, according to researchers from Columbia University Medical Center.

Nevertheless, the stakes are too high not to address this complex, insidious situation, especially due to the increased mortality, morbidity, and medical costs stemming from a diabetes and depression diagnosis. For example, as Dr. Manigault notes in this issue’s cover article, there is a striking twofold increase for new-onset infarction in patients with diabetes and major depressive disorder, according to American Diabetes Association guidelines.

It is crucial, therefore, for healthcare providers, including pharmacists, to identify opportunities to ameliorate the impact of comorbid diabetes and depression, because the bidirectional relationship between these diseases has major implications for individual patients and the healthcare system as a whole.